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The Open Neurology Journal, 2012, 6, (Suppl 1-M11) 179-186 179 Open Access Damage of Collagen and Elastic Fibres by Borrelia Burgdorferi – Known and New Clinical and Histopathological Aspects

Kurt E. Müller*

Medical Practice for Dermatology, Venerology, Occupational Dermatology and Environmental Medicine, Kempten, Bavaria, Germany

Abstract: Lyme Borreliosis, or Lyme’s disease, manifests itself in numerous skin conditions. Therapeutic intervention should be initiated as soon as a clinical diagnosis of is made. The histopathology of some of the skin conditions associated with Lyme Borreliosis is characterised by structural changes to collagen, and sometimes also elastic fibres. These conditions include , et atrophicus and acrodermatitis chronica atrophicans. More recently, further skin conditions have been identified by the new microscopic investigation technique of focus floating mi- croscopy: annulare, lipoidica, necrobiotic xanthogranuloma, erythema annulare centrifugum, inter- stitial granulomatous dermatitis, cutaneous sarcoidosis and lymphocytic infiltration; these conditions also sometimes cause changes in the connective tissue. In the case of ligaments and tendons, collagen and elastic fibres predominate struc- turally. They are also the structures that are targeted by Borrelia. The resultant functional disorders have previously only rarely been associated with Borreliosis in clinical practice. Ligamentopathies and tendinopathies, spontaneous ruptures of tendons after slight strain, dislocation of vertebrae and an accumulation of prolapsed intervertebral discs as well as ossifi- cation of tendon insertions can be viewed in this light. Keywords: Lyme Borreliosis, collagen fibres, elastic fibres, skin, connective tissue, tendons, ligaments, diverticulum.

INTRODUCTION annulare centrifugum [13], microbial eczema [Müller: un- published], [3; Müller unpublished], Lyme Borreliosis causes skin symptoms at all stages of lichenoides chronica [24], acrodermatitis papulosa the disease [1-3]. The most common skin conditions associ- [Gianotti-Crosti syndrome], [21] perifollicu- ated with Lyme Borreliosis are morphea [1, 4-10], lichen litis [24], panniculitis [25,26], lymphocytoma [synonym: sclerosus et atrophicus [LSA; 1, 4-6, 10-12], and acroderma- lymphadenosis cutis benigna [Bäfverstedt’s syndrome; 27- titis chronica atrophicans [ACA; 1, 6-8, 13], which possess 29], benign lymphocytic infiltration [Jessner-Kanof syn- an acute inflammatory stage followed by a chronic atrophic drome; [30,31], sarcoidosis [32], B-cell lymphoma [33], stage (Table 1-3). These skin conditions associated with pseudolymphoma [Müller: unpublished], Raynaud’s syn- Lyme Borreliosis are characterised by pronounced histopa- drome [34] and racemosa [Müller; unpublished]. thological changes of the collagen fibres, but also occasion- This paper will deal with skin conditions that cause histopa- ally the elastic fibres in their connective tissue structures thological changes to the collagen and elastic fibres. [6,1,9,12,13]. The following also display similar disorders of their connective tissue: , and necrobiotic xanthogranuloma [1]. With the aid Focus Floating Microscopy (FFM) of a new histopathological technique, these skin conditions After the introduction of FFM, a number of dermatologi- have also been found to contain Borrelia [13-17]. In some cal conditions could be attributed to Lyme Borreliosis. FFM cases, LB was also detected in the connective tissue of pa- is a modified immunohistochemical investigation technique tients suffering from pseudopelade of Brocq [18], Sudeck’s in which several strategies are combined in order to be able dystrophy [19], hemifacial [20] and scleroedema of to identify microorganisms in tissue sections. In FFM, tissue Buschke [21]. sections are investigated in two planes: horizontally in a There are also other skin conditions that do not display serpentine-like pattern, as is usual in cytology, and vertically, any particular connective tissue changes and optionally may focussing through the entire thickness of the section (nor- occur as reactive skin conditions in Lyme Borreliosis. These mally 3-4 µm). The tissue section is stained bright red with include urticaria [22], [23], erythema aminoethylcarbazol (AEC) and a light source is used that shines through the specimen approximately 10 times more strongly than usual. Thus a good contrast can be established *Address correspondence to this author at the Mozartstrasse 16, D 87435 between the microorganisms and the bright yellow collagen, Kempten, Germany; Tel: +49 (0)831 5126729; Fax: +49 (0)831 5409294; optimising identification of the pathogen [14]. E-mail: [email protected]

1874-205X/12 2012 Bentham Open 180 The Open Neurology Journal, 2012, Volume 6 Kurt E. Müller

Table 1. Pathohistology of Morphea

Early Phase Sclerotic Stage

Oedematous swelling of collagen fibres Homogenised collagen fibre bundle

Cell infiltration of , eosinophils and plasma cells Decrease in strength of fibrils

Reduction in cell infiltrates

Slit-like narrowing of vessels

Loss of accessory structures of the skin

Hyaline sclerotic transformation of corium

Table 2. Pathohistology of Acrodermatitis Chronica Atrophicans

Inflammatory Stage Atrophic Stage

Oedematous swelling of hyalinised collagen fibres Atrophy with disappearance of elastic fibres

Undulating or ribbon-like perivascular lymphocytic infiltrates Nests of Borrelia can be found in the collagen fibre bundles

Subepidermal haemorrhagic blisters due to infiltration of blood

Deposit of IgM, IgG, IgA, complement and fibrin

Table 3. Pathohistology of Lichen Sclerosus et Atrophicus

Initial Phase Late Phase

Oedematous swelling of hyalinised collagen fibres Atrophy with disappearance of elastic fibres

Undulating or ribbon-like perivascular lymphocytic infiltrates Foci of Bb can be found in the collagen fibre bundles

Subepidermal haemorrhagic blisters due to infiltration of blood

Deposit of IgM, IgG, IgA, complement and fibrin

Cutaneous Manifestations of Lyme Borreliosis with In- homogenised collagen fibre bundles, a reduction in fibril volvement of the Connective Tissue strength, decrease in cell infiltration, slit-like vessels and loss of accessory structures of the skin in a hyaline sclerotic co- Morphea rium, in which only the arrector pili muscles are maintained Clinical finding: At the beginning a spot-like focus can [1, 6, 35]. Borrelia were detected in foci of morphea using be seen with slight inflammatory erythema radiating out- FFM [9]. wards on all sides. It can occur in isolation or in groups. The erythema gradually completely disappears in the centre into Acrodermatitis Chronica Atrophicans (ACA; Herx- a disc-like, ivory-coloured hardened area, that is surrounded heimer’s Disease) by a bluish-violet, lilac-coloured ring [1,7]. Atrophy devel- ops in the late phase, which is a hyper-pigmented dirty grey- Clinical finding: ACA tends to occur over the large joints ish-brown colour at the edges but usually without pigment in and distal parts of the extremities. It can also be seen on the the centre. During this phase there may be a loss of hair and face and trunk. It initially causes an oedematous skin swell- sebaceous glands. Morphea tends to occur on the trunk, less ing with slight erythema. Thread-like erythema may also commonly on the extremities. The foci may develop indi- develop on the extremities, characterised as ulnar striations vidually and be disseminated but also merge into patches or on the forearms and tibial striations on the legs. As there are become generalised and are then difficult to differentiate usually no subjective symptoms during this phase, early from [1, 4-6, 10, 35, 36]. of ACA of stage 1 Borreliosis usually goes unnoticed. In stage Pierini and Pasini [37, 38] is now considered to be an abor- 2 there is pronounced atrophy of the skin, which becomes tive form of morphea [39, 40]. thin, flaccid and creases like cigarette paper. The following symptoms then develop: hair loss, telangiectasias, varicose Histopathology (Table 1): Two phases can be distin- veins and altered pigmentation [1, 3, 8, 35]. guished histologically. The early phase is associated with an oedematous swelling of the collagen fibres and cell infiltra- Histopathology (Table 2): ACA starts with an inflamma- tion of lymphocytes, eosinophilic granulocytes and plasma tory oedematous stage of the corium associated with perivas- cells. This is followed by the second, sclerotic stage with cular lymphohistiocytic cell infiltration and plasma cells. This turns into an atrophic stage, where swelling and ho- Damage of Collagen and Elastic Fibres by Borrelia Burgdorferi The Open Neurology Journal, 2012, Volume 6 181 mogenisation of the fibres and disappearance of collagen and quently - in 92.7% of cases (38/41) - than in the atrophic late elastic fibres is observed. This stage enables a differential stage where there was less inflammation – 26.7% of cases diagnosis to systemic scleroderma to be made, where the (4/15). elastic fibres are not affected. There is also narrowing of the corium with infiltration of lymphocytes, histiocytes and a Granuloma Annulare (GA) large number of plasma cells [1,3]. Borrelia were detected in 50 out of 51 patients with ACA [15]. FFM was more sensi- Clinical finding: One can see small, sharply-delineated, tive than Polymerase Chain Reaction (PCR; 96.0% versus slightly reddened papules that are slightly shiny. As these 45.2%) and almost as specific (99.4% versus 100%) in fresh grow they become bow or ring-shaped and the middle sinks bites, EM, lymphocytoma and ACA. level with the skin. Secondary changes such as erosions and ulcers develop. Preferred sites are the backs of the hands and Lichen Sclerosus et Atrophicus (LSA) feet, but also joints of the hands, elbows, joints of the feet and buttocks. A distinction is made between the erythema- Clinical finding: Initially one can detect small porcelain- tous, subcutaneous, disseminated, perforating and plaque coloured to bluish-white round to oval atrophic foci, which forms [1, 3, 35]. The presence of against Bb in later merge into irregularly-configured larger areas. Older cases of GA had been published in 1987 [41]. foci develop fine parchment-like folds on the surface with Histopathology: Histologically one can determine two follicular and cone-shaped papules. Preferred distinct variants: foci of necrobiotic degenerated collagen, sites for LSA in men and women are the side of the neck, sometimes surrounded by histiocytes in palisade-like forma- shoulders, the flexor side of the forearms, submammary tion. In the more discrete (mild) course the histiocytes are region, and anal and perianal area as well as the genitals. A embedded in the collagen. Histiocytic pseudorosettes were short frenulum is often the commonest sign of LSA in men. described in GA associated with a Borrelia [42, Shrinking of the can lead to secondary in 43]. These are free-floating bundles of collagen that are men, the worst variant of which is xerotica obliter- surrounded by histiocytes. In 86.66% of cases that were ans. The equivalent advanced form of genital signs of LSA investigated histologically (13/15), histiocytic pseudorosettes in women is , which are lesions with ten- were detected with degeneration of the collagen. The frag- dency to malignancy [1, 3, 4, 6, 10, 35]. mented collagen fibres are surrounded by CD68-expressing Histopathology (Table 3): Initially the hyalinised colla- granulomatous cells [42]. Borrelia were detected in 80.9% of gen fibres and cell undulating and ribbon-like infiltrates biopsies (127/157) of GA investigated [17]. In 85.2% of the become impregnated with oedema. Blood infiltration leads to cases investigated, the pathogen was detected in the localised subepidermal haemorrhagic blisters. Deposits of immu- form, i.e. much more commonly than in the diffuse form. noglobulins IgA, IgG and IgM and complement and fibrin are found. The lymphatic vessels are dilated. During the late Necrobiotic Xanthogranuloma (NXG) phase, disappearance of elastic fibres leads to atrophy [1, 3, 6, 35]. B. burgdorferi sensu lato was detected in 63% of Clinical finding: One can find reddish-yellow to brown patients with LSA [12]. Detection was significantly higher in papules, annular plaques, and teleangiectasias that tend the inflammatory initial phase of LSA (80%) than in the to predominate in the periorbital region, but are also found atrophic late phase (33.3%). on the trunk and proximal extremities [44, 45]. NXG is fre- quently associated with paraproteinaemia, other neoplasms Necrobiosis Lipoidica (NL) and lymphoproliferations [46, 47]. It has also been described in connection with scleroderma [48]. Clinical finding: Irregularly-configured, sharply delinea- Histopathology: The biopsies show granuloma without a ted, disc-like, atrophic plaques criss-crossed with teleangiec- palisade-like formation with numerous polynuclear giant tasias with a yellow to brownish-reddish-yellow sclerotic cells and extensive necrobiotic areas over the entire . hard centre. Several foci may merge. In 30% of cases ulcers In the central atrophic region of annular plaques there may may develop which are difficult to heal; these have a greasy be complete loss of elastic fibres [1]. In 6 out of 7 cases of yellow necrotic background and indurated edges. As these NXG, Borrelia were found on their own, in pairs and in heal the skin becomes atrophied and the integumentary ap- clusters. In 4 out of 6 positive cases, PCR was positive. In 2 pendage is lost [1, 35]. cases it was normal [16]. Histopathology: The shows no specific changes. In the middle and lower dermis, and sometimes also Pseudopelade of Brocq the subcutaneous adipose tissue, nodular or striated granu- lomatous inflammation can be found consisting of histio- Clinical finding: Irregularly-configured, merging foci cytes, epitheloid cells and polynuclear giant cells as well as which remain sharply delineated compared with the unaf- focal and plasma cell nests. Individual lymph fected skin. The affected skin usually glistens whitish-yellow follicles may also form. In addition to these inflammatory and is atrophically thinned like cigarette paper and without components, extensive changes may occur to the collagen, follicular openings. Many hairs are lost, some tufts may which are described as collagen necrobiosis. The walls of the remain [1]. A link with Borreliosis has been reported [18]. vessels may swell and the vessels close [1]. Borrelia were Histopathology: There is sclerosis with destruction of the detected with FFM in 42 (75%) of the 56 patients with NL elastic fibres and follicular openings. The former follicle investigated [15]. Where there was a stronger inflammatory areas are characterised by collagen fibres that run perpen- reaction, Borrelia were detected significantly more fre- 182 The Open Neurology Journal, 2012, Volume 6 Kurt E. Müller dicular to the surface of the skin and arrector pili muscles and prevent the collagen fibres from becoming entangled that were maintained. The perifollicular and perivascular [49]. lymphocytic inflammations are only moderately pronounced Reticular fibres are a third type of fibre that can be dif- [1, 35]. ferentiated histologically from collagen fibres by their ability to become stained with silver. That is why they are also Structure and Function of Tendons and Ligaments described as argyrophilic fibres. They are usually very deli- cate in structure, never occur in great quantities or thick Tendons are support tissues which anchor the skeletal bundles and are optically anisotropic. They have a thin skin muscle in the periosteum. They are formed predominantly and their task is to encase. They can be found at the edges from collagen, to a lesser extent elastic fibres as well as bordering the connective tissue and adjacent non-connective intercellular substance. In short tendons the bundles of fibres tissue. The general consensus is that reticular cells produce run parallel with one another. In long tendons they wind collagen fibres [49]. around one another in steep spirals. Bundles of tendon fibres increase cross-cohesion and strength against shearing. The Interaction of Borrelia Burgdorferi with Structures in formation of fine waves enables the tendon to lengthen by Tendons and Ligaments approximately 4% under stress. This causes a certain loss of transferred force [49]. However, it enables a more gentle Borrelia are capable of breaking down soluble and in- exertion of the muscles and reduces the risk of injury. The soluble ground substance within the extracellular matrix tendon develops gradually from the muscle and attaches with [51]. They activate metalloproteases, cause collagen to dis- tendon fibres (Sharpey´s fibres) to the periosteum or peri- solve and can colonise as microcolonies in collagen fibres chondrium. In addition to collagen fibres, tendons that radi- [52]. They inhibit the regeneration of collagen promoted by ate into soft tissue like those of the mimetic muscles, the skin fibronectin, and hence delay the healing process or prevent it or the tongue muscles have numerous elastic fibres that ex- completely [53]. Binding to adhesins such as glucosamine tend like bristles into the soft tissue [49]; (Table 4). glycan-binding protein [54], fibronectin-binding protein [55] Ligaments are high-tensile connective tissue ribbon-like and the proteoglycan decorin [11, 56, 57] are described. The structures that sensibly limit the range of movement. Their last is probably responsible for the destruction of collagen, collagen fibres are not branched. They are not able to dis- since direct binding to collagen I and II has not been de- tend, they increase tensile strength and are flexible. A tected. Mice with decorin deficiency were resistant to Borre- healthy ligament only tears at a load of between 6 and 10 lia [58]. Binding of the surface protein BmpA, BmpB, BmpC kg/mm². The elastic fibres of ligaments have varying thick- and BmpD to laminin inhibits cell-cell contact [59]. The nesses, have sharp contours and branch unlike collagen fi- same was established for the surface protein ErpX [60]. The bres; they also form networks. They can resist acids and involvement of gene conversion has also been established alkaline chemicals. They can only be made visible on fixed [61], as has the link to autoimmune disorders [62,63]. The specimens by staining with orcein and resorcin-fuchsin. persistence of Bb in human ligaments was described as early Elastic fibres have low resistance to distension. Once the as 1993 [64]. In primates, Borrelia have been detected in the extension force finishes they return to their original state. connective tissue of the aorta, the atria and the ventricles of Distension of up to 2.5 times the original state is reversible the heart [65]. In endomysium biopsy Bb was detected in [49,50]. dilative cardiomyopathy in humans too [66]. Using FFM, Bb was also determined in the intestinal wall of an own patient The combination of elastic and collagen fibres has a who had to undergo surgery for acute diverticulitis. Sero- functional significance. Collagen fibres, when arranged in logical tests revealed no antibodies [AB] in this case, even parallel, become gathered. If the fibre bundle is stretched the immunoblot test was normal. This is not surprising since longitudinally the elastic fibres involved become taut. As antibodies may not develop [11]. Activation of the conven- soon as the stretching force diminishes, the taut elastic fibres tional and alternative pathways of complement activation pull the collagen fibres back to their original state. They are and the lysis of Bb triggered by this is absent in those cases therefore critical to returning the ligament to the midpoint [11]. The lymphocyte transformation test [LTT] was used

Table 4. Structure and Task of Tendons and Ligaments

Tendon Ligament

Structure Tendon cells Unbranched collagen fibres which give tensile strength in the longitudinal direction

Intercellular substance Good flexibility

Tendon fibres made from collagen Slight distensibility

In addition net-like structured branched elastic fibres with good distensibility

Stable with acids and alkalis

Task Support tissue to anchor the skeletal muscle High-tensile connective tissue ribbon-like structure for sensible functional restriction of range with the periosteum of movement Damage of Collagen and Elastic Fibres by Borrelia Burgdorferi The Open Neurology Journal, 2012, Volume 6 183 diagnostically [2, 67, 68]. The lympho-proliferative immune Dysfunction of the Atlaido-occipital Joint response in EM, ACA, lymphocytoma and morphea was established as early as 1995 [9]. In agreement with the FFM The atlaido-occiopital joint has been reported to be an- result, LTT was positive to Borrelia antigens. There is a other common and clinically significant site for symptoms clinical link between Borreliosis and colon elongatum [71]. The structural change of the ligaments which fix the [Müller: unpublished cases]. atlas to the base of the skull [alar ligaments] or stabilise the dens axis [transverse atlantis liagments], have special sig- Clinically, the interaction of Borrelia with the glucosa- nificance owing to their complex effects on cranio- mine glycan hyaluronic acid is very significant. This is an mandibular function, vegetative control through sympathetic acid, high-viscous mucopolysaccharide that binds strongly to and parasympathetic nerves, the function of various centres water and occurs in ground substance as the free form, the of the brain stem, the induction of increased nitrogen oxide ester or bound to protein. It is used as a lubricant, to regulate and peroxynitrite formation [72, 73], increased production of water-binding and control permeability and diffusion. 1 g pro-inflammatory cytokines and cyclooxygenases [74], and hyaluronic acid can bind with up to 6 l water. This glucosa- finally also due to dislocation of vertebrae and intervertebral mine glycan is also able to prevent the penetration of infec- discs and accompanying myopathies [72]. tious microorganisms. The reproduction of Borrelia might also be promoted by hyaluronidase. Binding of surface pro- Dysfunction of the atlaido-occipital joint without trau- teins to hyaluronic acid causes a reduction in pH, inactiva- matic damage but correlated to chronic Lb has been de- tion of proteoglycans, a decrease in cross-linking and a re- scribed inducing a variety of symptoms [71]. 12 [18,8%] of duction in viscosity. Later on there may be displacement of the 64 patients reported had positive IgG antibodies in gap junctions whose task it is to regulate the transport of ELISA and 17 [26,6%] in immunoblot. IgM antibodies had organic and inorganic ions in tissues that are poorly supplied not been found in any of the cases. In 57 (89,1%) patients the with blood [69]. This relates to tendons and ligaments in stimulation index (SI) in lymphocyte transformation test particular. If this occurs, the initial oedematous swelling of (LTT) was pathologically increased (SI > 3,0) in one of the the tendons will disappear, and finally the ligament fibres four antigens investigated (B. burgdorferi, B. afzelii, B. will dry out. The risk of tendon rupture increases in associa- garinii, Ospc). A functional magnetic resonance imagin tion with damage to the collagen fibres. The extent to which (MRI) scan was carried out on 28 (49,1 %) of the 57 patients elastic fibres are also damaged was previously unknown. The with pathological SI in LTT. Structural damage has been function of porins is also altered by Bb [70]. described to the alar ligament, the transverse axis ligament included involvement of the spinal cord medulla with me- chanically triggered myelopathy as it has been reported in Clinical Symptoms of Lyme Borreliosis in Tendons and cases following traumatic damage [75]. As published before Ligaments [76], the number of CD57+ natural killer cells (NK-cells) While it is generally recognised that arthritis is a possible was determined. 36 (78,3 %) of the examined 46 patients condition associated with Lyme Borreliosis and osteoarthritis showed significant reduction of this cell type. is frequently the first sign in a joint, the involvement of ten- dons and ligaments was previously not given much consid- CONCLUSIONS eration although the high affinity of Borrelia to collagen and elastic fibres was already recognised in the histopathological Morphological changes of the skin are histologically changes of skin conditions associated with Lyme Borreliosis. characterised by very similar pathological changes to the It is notable clinically that the symptoms in tendons and collagen and also elastic fibres in a whole range of skin con- ligaments frequently develop independently of special strain ditions that occur with Lyme Borreliosis. Using FFM Bb was or trauma to the affected tendons and/or ligaments and that detected in the tissue within a clear time interval relative to there is an apparent contradication between the symptoms disease transmission. Using this technique, it was possible to experienced and that triggering event [71]. confirm skin conditions already known to be associated with Borreliosis and recognise new ones such as necrobiosis li- Insertional tendinopathies are often observed clinically. poidica or necrobiotic xanthogranuloma. The histologically- The most common locations are the epicondylitis humeri detected persistence of the pathogen does not correlate relia- [tennis elbow], the meeting point of the tendons of the sarto- bly with PCR or serological parameters. rius, gracilis and semitendinosus muscles in the medial re- gion of the knee joint [pes anserinus superficialis]. The Collagen and elastic fibres are essential structural ele- symptoms may radiate from there a hands-width cranially to ments of tendons and ligaments. Few publications to date the upper leg. The Achilles [or calcaneal] tendon or plantar have dealt with the possibility of their being affected in the fascia ligament may also be affected. Ruptures of the exten- context of Lyme Borreliosis, even though the first indica- sor tendons of the fingers, the quadriceps tendon, of cruciate tions of this were published over almost two decades ago ligaments and Achilles tendon and spontaneous vertebral [64]. There is evidence that the presence of decorin in ten- dislocations have been seen clinically at low levels of strain dons and ligaments plays a critical role in infestation. in patients who were suffering from Lyme Borreliosis. In Decorin-deficient mice were resistant to Bb. The extent to addition, carpal tunnel syndrome [CTS] and calcifications of which the genetic expression of decorin plays a role has not the tendon insertions [periarthropathia homeroscapularis, been investigated to date. From own results on two brothers calcifications of the patellar ligament, achillodynia and who contracted Lyme Borreliosis one after the other with Haglund’s heel] have also been observed in this connection. pronounced symptoms in the tendons and ligaments, ele- Eosinophilic fasciitis [Shulman’s syndrome, Shulman‘s ments of individual susceptibility in addition to the special fasciitis] is described in connection with LB [21]. characteristics of the pathogen can be anticipated to play a 184 The Open Neurology Journal, 2012, Volume 6 Kurt E. Müller role in the symptoms in individual cases. Spontaneous rup- LB = Lyme Borreliosis tures of tendons and ligaments that are triggered by no or LTT = lymphocyte transformation test only slight trauma are clinically suspicious of Lyme Bor- reliosis. It would be good if, when treating tendons and NK = natural killer celles ligament damage surgically, the possibility of Lyme Bor- NL = necrobiosis lipoidica reliosis would be considered more often and tissue obtained for histopathological examination using FFM. NXG = necrobiotic xanthogranuloma Various factors are now known that imply that an iso- Osp = outer surface protein lated case of LB will not be overcome either by the individ- PCR = polymerase chain reaction ual power of the immune system or by the treatment imple- mented, but will take a chronic course. Animal studies have TNF = tumor necrosis factor shown that even with adequate formation of antibodies only those cell populations that were carriers of surface markers CONFLICT OF INTEREST were eliminated. Elimination of the entire population was not The authors confirm that this article content has no conflicts achieved [57]. Moreover, only a proportion of patients de- of interest. velop sufficient antibodies. In cases such as this even the complement activation that leads to lysis of the pathogen ACKNOWLEDGEMENT does not occur [11]. In neuron and astrocyte cultures as well as in the brains of three patients, pleomorphic and cystic I wish to thank Primar Priv. Doz. Dr. Klaus Eisendle, forms of Borrelia that indicate resistance to pathogens were Bolzano/Alto Adige, Italy (formerly of the University Clinic detected extra and intracellularly using dark field micros- of Dermatology Innsbruck/Austria) for performing a histo- copy, histochemistry and immunohistochemistry. The find- logical investigation of a diverticulum for Borrelia burgdor- ings were similar to those obtained with Treponema pal- feri using focus floating microscopy. lidum [77]. Tendons and ligaments are a structurally and topographi- REFERENCES cally ideal retreat for Borrelia. Their involvement is a further [1] Braun-Falco O, Plewig G, Wolff HH: Dermatologie und Vene- factor to indicate a chronic course of the disease. Serological rologie. Berlin: Springer Verlag 1995. diagnostic techniques proved to be inadequate in [2] Hopf-Seidel P. Krank nach Zeckenstich. München: Knaur Taschenbuchverlag 2008. cases such as this, possibly because the formation of antibod- [3] Satz N. Klinik der Lyme Borreliosis. Bern: Verlag Hans Huber ies is inhibited by the pathogen [11]. Immunological investi- 2002. gation on immune cells has widened the diagnostic spectrum. [4] Aberer E, Stanek G: Histological evidence for spirochetal origin of The sensitivity of LTT was superior to serological investiga- morphea and lichen sclerosus et atrophicans. Am J Dermatopathol 1987; 9: 374-9. tion of antibodies in the ELISA or immunoblot tests and [5] Aberer E, Stanek G: Evidence of spirochetal origin of circumscript correlated well with clinical symptoms. FFM was able to scleroderma (Morphea). Acta Dermatol Verol 1987; 67 (3): 225-31. detect the pathogen directly in numerous skin conditions [6] Altmeyer P: Zur Klassifikation der zirkumskripten Sklerodermie associated with LB, regardless of the results of serology or of (CS): Multizentrische Untersuchung an 286 Patienten. Hautarzt PCR. LTT is a useful addition to the haematological diag- 1990; 41: 16-21. [7] Büchner SA: Morphea – eine zeckenübertragene Borreliosis der nostic spectrum, especially for the diagnostic of LB of ten- Haut? Ein Beitrag zur zirkumskripten Sklerodermie. H + G Zeitsch dons and ligaments, as histopathology in those cases rarely Hautkr 1989; 64: 661-9. can be done. [8] Büchner SA, Lautenschlager S, Itin P, Bircher A, Erb P: Lym- phoproliferative Responses to Borrelia burgdorferi in Patients with Erythema Migrans, Acrodermatitis Chronica Atrophicans, Lym- ABBREVIATIONS phadenosis Benigna Cutis and Morphea. Arch Dermatol 1995; 131(6): 673-7. AB = antibodies [9] Einsendle K, Grabner T, Zelger B. Morphea – a manifestation of ACA = acrodermatitis chronic atrophicans infection with borrelia species? Br J Dermatol 2007; 157:1189-98. [10] Neubert U, Aberer U, Rufli T. Localized Scleroderma and Lichen AEC = aminoethylcarbazol Sclerosus et Atrophicus: Manifestation of Borrelia burgdorferi In- fection? In Aspects of Lyme Borreliosis. Edited by Weber K, Bb = borrelia burgdorferi Burgdorfer W. Berlin: Springer Verlag 1992; pp. 240-7. [11] Aberer E. Lyme Borreliosis - Update. JDDG 2007; 5: 406-13. Bmp = borrelia membrane protein [12] Einsendle K, Grabner T, Kutzner H, Zelger B. Possible role of CD = cluster of differentiation Borrelia burgdorferi sensu lato infection in lichen sclerosus. Arch dermatol 2008; 144(5): 591-8. CTS = carpal tunnel syndrome [13] Einsendle K, Zelger B. The expanding spectrum of cutanous bor- reliosis. G Ital Venereol 2009; 144(2):157-71. EM = erythema migrans [14] Einsendle K, Grabner T, Zelger B. Focus floating microscopy “gold standard” for cutanous borreliosis? Am J Clin Pathol 2007; Erp = OspE/F related protein 127: 213-22. [15] Einsendle K, Baltaci M, Kutzner H, Zelger B. Detection of spiro- FFM = focus floating microscopy chetal microorganisms by focus floating microscopy in necrobiosis GA = granuloma annulare lipoidica patients from central Europe. Histopathol 2008; 52(7): 877-84. IFN = interferon [16] Zelger B, Einsendle K, Mensing C, Zelger B: Detection of spiro- chetal microorganisms by focus floating microscopy in necrobiotic LSA = lichen sclerosus et atrophicus xanthogranuloma. J Am Acad Dermatol 2007, 57:1026-30. Damage of Collagen and Elastic Fibres by Borrelia Burgdorferi The Open Neurology Journal, 2012, Volume 6 185

[17] Zhang JR, Norris SJ. Variations of the Borrelia burgdorferi Gene Borrelia burgdorferi DNA sequences by a highly sensitive PCR- vIsE Involves Cassette-specific, Segmental Gene Conversion. In- ELISA. J Acad Dermatol 2003; 48: 376-84. fect Immun 1998; 66(8): 3698-704. [44] Kossard S, Winkelmann RK. Necrobiotic xanthogranuloma. Aus- [18] Schwarzenbach R, Djawari DJ. Pseudopelade Brocq – mögliche tral J Dermatol 1980; 21: 85-8. Folge einer Borreliosis III. Hautarzt 1998; 49: 835-7. [45] Mehregan DA, Winkelmann RK. Necrobiotic xanthogranuloma. [19] Neumann RA, Aberer E, Stanek K. Evidence for spirochetal origin Arch Dermatol 1992; 128: 94-100. of Sudeck´s atrophy (algodystrophy, reflex sympathetic dystrophy). [46] Ito Y, Nashimura K, Yamanaka K, et al. Necrobiotic xanthogranu- Arch Orthop Trauma Surg 1989; 108(5): 314-6. lomaa with paraproteinemia; an atypical Case. J Dtsch Dermatol [20] Ventura F, Gomes J, Vilarinho C, et al. Parry-Romberg syndrome: Ges 2008; 6(1): 40-3. A possible association with Lyme borreliosis. J Infect Dis Immun [47] Kossard S. Winkelmann: Necrobiotic xanthogranuloma with para- 2011; 3(3): 36-9. proteinemia. J Am Acad Dermatol 1980; 40: 257-70. [21] Trevisan G. Atypical dermatological manifestations of Lyme [48] Russo GG: Necrobiotic xanthgranuloma with scleroderma. Cutis borreliosis. Acta Dermatoven Alpina, Pannonica et Adriatica 2002; 70: 311-16. 2001;10(4):1581-2979. [49] Benninghoff A, Goerttler K: Lehrbuch der Anatomie. Bd.1: Allge- [22] Steere AC, Bartenhagen NC, Craft JE. The early clinical manifesta- meineAnatomie und Bewegungsapparat. München: Urban & tion of . Ann Intern Med 1983; 99: 76-82. Schwarzenberg 1964. [23] Schuttelaar ML, Laeijendecker R, Heinhuis RJ, Van Joost T. [50] Schmidt W: Bewegungssystem – Grundlagen. In: Bob A, Bob K, Erythema multiforme and persistent erythema as early cutanous Eds. Anatomie – Duale Reihe. Stuttgart: Thieme Verlag 2006; 197- manifestations of Lyme disease. J Acad Dermatol 1997; 37: 873-5. 224. [24] Menni S, Pistritto G, Gelmetti C, Stanta G, Travisan G. Pityriasis [51] Coleman JL, Roemer EJ, Benach JL. Plasmin-coated Borrelia lichenoides-like lesions with perifolliculitis in Lyme Borreliosis. burgdorferi degrades soluble and insoluble components of the Europ J Pediat Dermatol 1994, 4:77-80. mammalian extracellular matrix. Infect Immun 1999; 67(8): 3929- [25] Hassler D, Zorn J, Zöllner L. Noduläre Pannikulitis. Eine Ver- 36. laufsform der Lyme Borreliosis? Hautarzt 1992; 43:134-8. [52] Zambrano MC, Beklemisheva AA, Bryksin AV, Newman SA, [26] Kramer N, Rickert RR, Brodkin RH, Rosenstein ED. Septical Cabello FC. Borrelia burgdorferi binds to, invades, and colonizes panniculitis as a manifestation of Lyme disease. Am J Med 1986; native Type I collagen Lattices. Infect Immun 2004, 72(6): 3138- 81: 149-52. 46. [27] Picken RN, Strle F, Ruzic-Sabiljic E, et al. Molecular subtyping of [53] Grab DJ, Kennedy R, Philipp MT. Borrelia burgdorferi posses a Borrelia burgdorferi sensu lato isolates from five patients with collagenolytic activity. FEMS Microbiol Lett 1996;144(1): 39-45. solitary lymphocytoma. J Invest Dermatol 1997;108(1): 92-7. [54] Parveen N, Leong M. Identification of a candidate glycosamingly- [28] Strle F, Pleterski-Rigler D, Stanek G, Pejovnik-Pustinek A, Ruzie can-binding adhesin of Lyme disease spirochete Borrelia burgdor- E. Cimperman J: Solitary borrelial lymphocytoma: report of 36 feri. Mol Microbiol 2000; 35(5): 1220-34. cases. Infection 1992; 20: 201-6. [55] Brisette CA, Bykowski T, Cooley AE, Bowman A, Stevenson B. [29] Weber K, Schierz G, Wilske B, Prac-Mursic V: Das Lymphozytom Borrelia burgdorferi RevA Antigen Binds Host Fibronectin. Infect – eine Borreliosis? Zentralbl Hautkr 1985; 60: 1585-98. Immunol 2009; 77(7): 2802-12. [30] Abele DC, Anders KH, Chandler FW: Benign lymphocytic infiltra- [56] Guo BP, Norris SJ, Rosenberg LC, Höök M. Adherence of Borrelia tion (Jessner-Kanof: Another manifestation of Borreliosisis. J Am burgdorferi tot he Proteoglycan Decorin. Infect Immun 1995; Acad Dermatol 1989; 21: 795-7. 63(9): 3467-72. [31] Ziemer M, Grabner T, Einsendle K, Baltaci M, Zelger B: Granu- [57] Liang FT, Jacobs MB, Boers LC, Philipp MT. An immune evasion loma annulare - a manifestation of infection with borrelia species? J mechanism for spirochetal persitence in Lyme borreliosis. J Exp Cutan Pathol 2008, 35(11): 1050-7. Med 2002; 195(4): 415-22. [32] Derler AM, Einsendle K, Baltaci M, Obermoser G, Zelger B: High [58] Brown EL, Wooten RM, Johnson BJB, et al. Resistance to Lyme prevalence of Borrelia like organisms in skin biopsies from sarcoi- disease in decorin-deficient mice. J Clin Invest 2001; 107(7): 845- dosis patients from Western Austria. J Cutan Pathol 2009; 52. 36(12):1262-8. [59] Verma A, Bristte CA, Bowman A, Stevenson B. Borrelia [33] Goodlad JR, Davidson MM, Hollowood K, et al. Primary cutanous burgdorferi BmpA is Laminin-Binding Protein. Infect Immun B-cell lymphoma and Borrelia burgdorferi infection in patients 2009; 77(11): 2802-12. from the highlands of Scotland. Am J Surg Pathol 200; 24: 1279- [60] Brisette CA, Verma A, Bowman A, Cooley A, Stevenson B. The 85. Borrelia burgdorferi outer-surface protein ErpX binds mammalian [34] Kristof V, Bozsik BP, Szirtes M, Simonyi J. Lyme borreliosis and laminin. Microbiology 2009; 155: 863-72. Raynaud´s syndrome. Lancet 1990; I: 975-6. [61] Ziemer M, Einsendle K, Müller H, Zelger B. Lymphocytic infiltra- [35] Altmeyer P, Bacharach-Buhles M. Springer Enzyklopädie Derma- tion of the skin (Jessner-Kanof) but not reticular erythematous tologie, Allergologie, Umweltmedizin. Berlin: Springer Verlag mucinosis occasionally represent clinical manifestations of borre- 2002. lia-associated pseudolymphoma. Br J Dermatol 2009, 161(3):583- [36] Ross SA, Sánchez JL, Taboas JO: Spirochetal forms in dermal 90. lesions of morphea and lichen sclerosus et atrophicus. Am J Der- [62] Sarafova S. Borrerlia burgdorferi – Evasion of the Immun System. matopathol 1990; 12: 597-602. Available at: http://www.bio.davidson.edu/people/sosarafova/Ass- [37] Pasini A: Atrofodermia idiopatica progressiva. G Ital Dermatol ets/Bio307/meprasse/page06.html 1923; 58: 785. [63] Singh SK, Girschick HJ: Lyme borreliosis: from infection to auto- [38] Pierini L, Vivoli D. Atrofodermia progressiva (Pasini). G Ital immunity. Clin Microbiol Infect 2004; 10(7): 598-614. Dermatol 1936; 77: 403-9. [64] Häupl T, Hahn G, Rittig M, et al. Persistence of borrelia burgdor- [39] Büchner SA, Rufli T. Atrophoderma of Pasini and Pierini. Clinical feri in ligamentous tissue from a patient with lyme borreliosis. and histological findings and antibodies to Borrelia burgdorferi in Arthitis Rheum 1993; 36(11): 1621-6. thirty-four patients. J Am Acad Dermatol 1994; 30(3): 441-6. [65] Cadavid D, Bai Y,Hodzic E, Narayan K, Barthold SW, Pachner [40] Kohler J, Wokalek H, Thoden U. Atrophodermia Pasini-Pierini mit AR. Cardiac involvement in non-human primates infected with the lokalem Schmerzsyndrom – eine Borreliainfektion? Der Schmerz Lyme diease spirochete Borrelia burgdorferi. Lab Invest 2004; 1988; 2(1): 44-5. 84(11):1439-50. [41] Kuske B, Schmidly J, Hurzika T, Cueni M, Rufli T. Antibodies [66] Palecek T, Kuchynka P, Hulinska D, et al. Presence of Borrelia against Borrelia burgdorferi in patients with granuloma annulare. burgdorferi in endomyocard biopsies in patients with new-onset Congress in Lyme Borreliosis Update: Baden-Vienna 1987. unexplained dilated cardiomyopathy. Med Microbiol Immunol [42] Fernandez-Flores A, Ruzic-Sabljic E. Granuloma annulare 2010; 199(2): 139-43. displaying pseudorosettes in Borrelia infection. Acta Dermatoven [67] Valentine-Thon E, Ilsemann K, Sandkamp MA. A novel 2008;17(4):171-6. lymphocyte transformation test (LTT-MELISA®) for Lyme [43] Moreno C, Kutzner H, Palmedo G, Gorttler E, Carrasco I. Intersti- borreliosis. Diagn Microbiol Infect Disease 2006; 57: 27-34. tial granulomatous dermatitis with histiocytic pseudorosettes: a [68] Von Baehr, V. Die Labordiagnostik der Borreliainfektion.Umwelt- new histiopathologic pattern in cutanous borreliosis. Detection of medizin-gesellschaft 2009; 22(2):119-24. 186 The Open Neurology Journal, 2012, Volume 6 Kurt E. Müller

[69] Breves S. Borreliose. Colmberg: Medea-Verlag 2007. [74] Müller KE. Störung der immunoneurogenen Kommunikation. OM [70] Thein M, Bonde M, Bunikis I, et al. DipA, a pore-forming protein – Zs Orthomol Med 2008; 3: 9-13. in outer membrane of lyme disease Borrelia exhibits specificity for [75] Volle E. Diagnostische Methoden bei Verletzung am kraniozervi- permeation of dicarboxylates. 8th Anual Meeting of Deutsche Bor- kalen Übergang. In: Moskopp D, Wassmann, Eds. Neurochirurgie. reliosis-Gesellschaft. Wuppertal Germany, 2011. Submitted for Stuttgart: Schattauer 2007; pp. 555-60. publication. [76] Stricker RB: Decreased CD57+ lymphocyte subset in patients with [71] Müller KE. Erkrankungen der elastischen und kollagenen Fasern chronic Lyme disease. Immunol Lett 2001; 76: 43-8. von Haut, Sehnen und Bänder bei Lyme-Borreliose. umwelt- [77] Miklossy J, Kasa S, Zurn AD, McCall S, Yu S, McGeer PL. Per- medizin-gesellschaft 2009; 22(2):112-8. sisting atypical and casting forms of Borrelia burgdorferi and local [72] Kuklinski B. Das HWS-Trauma. Zwickau: Aurum-Verlag 2006. inflammation in Lyme neuroborreliosis. J Neuroinflamm 2008; [73] Pall ML. Explaining Unexplained Illnesses. Binghampton: Harring- 40(5):1742-2094. ton Press 2007.

Received: August 04, 2011 Revised: January 29, 2012 Accepted: July 02, 2012

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